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Helping the homeless Christian Jarrett examines psychology’s response

Incorporating Psychologist Appointments ÂŁ5 or free to members of The British Psychological Society

forum 266 news 274 careers 336 looking back 356

the nonexistent purpose of people 290 imagining harmonious relations 298 psychosocial support in the Red Cross 304 emergency response in Madrid 308


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The British Psychological Society Contact The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR tel 0116 254 9568 fax 0116 227 1314

Welcome to The Psychologist, the monthly publication of The British Psychological Society. It provides a forum for communication, discussion and controversy among all members of the Society, and aims to fulfil the main object of the Royal Charter, ‘to promote the advancement and diffusion of a knowledge of psychology pure and applied’. It is supported by www.thepsychologist.org.uk, where you can view this month’s issue, search the archive, listen, debate, contribute, subscribe, advertise, and more.

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We rely on your submissions, and in return we help you to get your message across to a large and diverse audience. See www.bps.org.uk/writeforpsycho

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‘Psychology is misrepresented by the media more than any other science, so it is very important that we present our work ourselves rather than leaving it to others. Writing for the The Psychologist and getting the help of its wonderful editors provides a marvellous opportunity to develop the skill of maintaining accuracy while avoiding jargon and not descending into mere chatter.’ Chris Frith, University College London

General Society e-mail mail@bps.org.uk Advertising Reach 50,000 psychologists at very reasonable rates. For rates and deadlines, e-mail psyadvert@bps.org.uk or tel 0116 252 9552 For job advertising, in print or online at www.psychapp.co.uk, e-mail psychapp@bps.org.uk tel 0116 252 9550

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Printed by Warners Midlands plc, Bourne, on 100 per cent recycled paper Please re-use or recycle See the online archive at www.thepsychologist.org.uk ISSN 0952-8229 © Copyright for all published material is held by The British Psychological Society, unless specifically stated otherwise. Authors, illustrators and photographers may use their own material elsewhere after publication without permission. The Society asks that the following note be included in any such use: ‘First published in The Psychologist, vol. no. and date. Published by The British Psychological Society – see www.thepsychologist.org.uk.’ As the Society is a party to the Copyright Licensing Agency (CLA) agreement, articles in The Psychologist may be photocopied by licensed institutional libraries for academic/teaching purposes. No permission is required. Permission is required and a reasonable fee charged for commercial use of articles by a third party. Please apply to the Society in writing. The publishers have endeavoured to trace the copyright holders of all illustrations in this publication. If we have unwittingly infringed copyright, we will be pleased, on being satisfied as to the owner’s title, to pay an appropriate fee.

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Managing Editor Jon Sutton Assistant Editor Peter Dillon-Hooper Production Mike Thompson Staff journalist Christian Jarrett Advertising Sarah Stainton Carl Bourton Editorial Assistant Debbie James

We can help you to advertise to a large, well-qualified audience see www.bps.org.uk/advertise and find out how. For full details of the policy and procedures of The Psychologist, see www.thepsychologist.org.uk. If you feel these policies and procedures have not been followed, contact the editor on jon.sutton@bps.org.uk, or the Chair of the Psychologist Policy Committee, Dr Paul Redford, on paul2.redford@uwe.ac.uk

Associate Editors Articles Vaughan Bell, Kate Cavanagh, Harriet Gross, Marc Jones, Rebecca Knibb, Charlie Lewis, Wendy Morgan, Tom Stafford, Miles Thomas, Monica Whitty, Barry Winter Conferences Sandie Cleland, Sarah Haywood International Nigel Foreman, Asifa Majid Interviews Nigel Hunt, Lance Workman History of Psychology Julie Perks

The Psychologist Policy Committee Paul Redford (Chair), Nik Chmiel, Olivia Craig, Helen Galliard, Jeremy Horwood, David Lavallee, Catherine Loveday, Stephen McGlynn, Sheelagh Strawbridge, Henck van Bilsen, Peter Wright, and Associate Editors

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forum in defence of the flashmob; Down’s; medicalising pregnancy; and more

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news and digest 274 the sexualisation of young people; flexible working; homelessness; DSM-5; back pain; inquests on ‘radiation deaths’; morsels from the Research Digest; and more

BORIS HEGER/REPORTDIGITAL.CO.UK

media making our science visible: Jeremy Horwood on the virtual revolution

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The nonexistent purpose of people Jesse Bering asks whether our minds have evolved to see humans as artefacts

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Deferred imitation in children and apes Children imitate after a delay, but can apes ape in a similar fashion? Lydia M. Hopper looks at the evidence

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Imagining harmonious intergroup relations Rhiannon N. Turner on her Doctoral Award-winning research

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304

Psychosocial support within a global movement Sarah Davidson on the work of the British Red Cross

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Emergency response psychology in Madrid Vaughan Bell talks to Teresa Pacheco Tabuenca

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THE ISSUE At a recent conference I attended, a speaker mentioned psychologist Denise Rousseau’s project ‘Science you can use’ (http://bit.ly/9xtk5L). The annual series would provide answers to practical questions of interest to practitioners and policy makers. Apparently the first round of well-intentioned submissions had led to the reaction ‘We have a problem – academics are not good at writing this kind of article’. Well, I hope that this issue showcases The Psychologist as a forum for this kind of writing. We hear from psychologists working with the homeless (p.284) and the former APA President who commissioned a Task Force on the topic (p.275 and p.360). Rhiannon Turner outlines novel ways to improve intergroup relations; Sarah Davidson describes her work with the British Red Cross in Haiti and other places; and Vaughan Bell talks to Teresa Pacheco Tabuenca about emergency response in Madrid (p.308). All psychologists making a difference, with science – and a publication – that you can use. Dr Jon Sutton (Managing Editor) PAUL BOX/REPORTDIGITAL.CO.UK

book reviews illusions with Richard Gregory; women leaders; phobias; and more

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society 318 President’s column; alcohol in Scotland; men’s health; Welsh taster; and more 336 careers cognitive psychology, teaching and research with Catriona Morrison; psychology and human rights; the latest jobs, and how to advertise looking back blindsight in hindsight, with Larry Weiskrantz

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one on one …with James Bray

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read discuss contribute at www.thepsychologist.org.uk

Helping the homeless Christian Jarrett examines psychology’s response to a disturbing social problem 284

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Much too much… much too young?

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likened Papadopoulos’s review to a 100page Cosmopolitan article. Janet StreetPorter, for the Independent on Sunday, highlighted Papadopoulos’s work for the media and beauty industry, even going so far as to question whether someone ‘who wears disgustingly expensive shoes is the best choice as a government expert on childrearing.’ Dr Papadopoulos retorted JOHN HARRIS/REPORTDIGITAL.CO.UK

The ‘pornification’ of British culture is causing numerous social ills including increased violence against women and teenage girls. That’s according to a new Home Office report Sexualisation of Young People Review by the Chartered Health and Counselling Psychologist Dr Linda Papadopoulos of London Metropolitan University (http://bit.ly/d2rgAF). Drawing on government research and statistics, lobby group publications and academic journals, together with input from a range of invited stakeholders, including Respect and Womankind, the review says that airbrushed adverts, sexist sitcoms, lurid music videos, easily-accessed internet porn, ‘lads mags’ and other forms of media are sending a message to children that women should make themselves sexually available and that men should be sexually dominant. Papadopoulos’s review, which follows similar publications in Scotland, the USA and Australia, further ties the sexualisation of modern culture to a rise in eating disorders, more and earlier cosmetic surgery, more girls aspiring to become pole dancers, acceptance of the ‘rape myth’, and sexual aggression. The review, commissioned by former Home Secretary Jacqui Smith in 2009, calls for more studies but says ‘we should acknowledge that the research and evidence…points clearly to the fact that sexualisation is having a negative impact on young people’s physical and mental health, and helping to normalise abusive behaviour towards women and children’. The review makes numerous recommendations, including: promoting gender equality in schools; making digital literacy a compulsory part of the school curriculum; lads mags to be put on the top shelf; sexy music videos to be broadcast only after the watershed; and a rating symbol system to show how much adverts have been digitally altered. The Home Secretary Alan Johnson welcomed the review and thanked Papadopoulos for her work. Janice Turner, for The Times, said the review ‘brims with good sense.’ However, other reactions were more hostile. Toby Young, in The Daily Telegraph, pointed to government figures showing that incidents of domestic violence against women have fallen, and

that ‘to suggest that the Home Office would employ me to conduct a review of such a serious nature because I am in her words “eye candy” is both offensive and ridiculous’ (see http://bit.ly/dkSYfa). Elsewhere, the Cambridge-based research consultant Alison MacLeod used her blog ‘the human element’ to highlight anomalies in the review (http://bit.ly/d5lXpX). For example, she traced the review’s claim that ‘a high proportion of young women in the UK aspire to work as “glamour models” or lap-dancers’ to a web survey conducted by internet TV company Lab TV, which found 63 per cent of 1000 girls thought Jordan was a good role model. The Psychologist asked Dr Petra Boynton, a social psychologist at UCL who specialises in research on sex, relationships and media, for her verdict. She told us that the review is ‘wellintentioned’ and ‘passionately written’ but that it was not ‘robust enough to inform policy and practice’. ‘The report mostly seems to have been informed by “desk-based research” with little indication of how literature was searched or appraised,’ Boynton said. ‘It is worrying that peer-reviewed research is presented as equivalent to a survey for Dove beauty products.’

‘Statistics, studies and surveys are mentioned but not fully explained or referenced, so it is difficult to generalise from them. Focus groups are described in brief with no details of participants, procedure or analysis. Young people are constructed as passive recipients objectified by the mass media. Research that discusses how young people understand and engage with mediated culture is absent.’ Boynton added that a similar report on ‘sexualised goods aimed at children’ for the Scottish Parliament (http://bit.ly/doAVUg) takes a more nuanced and investigative approach. ‘It is this work, rather than the Home Office consultation that should underpin our understanding of this area and direct future research and practice,’ she said. However, Dr Papadopoulos told us she was pleased that the media response to her report had been so positive and that some of her recommendations had already been taken up: ‘The PM spoke about backing the recommendation of an online “one-stop shop” for parents and for setting up a working group with the NSPCC to advise corporations on products targeted at children. An ongoing campaign on teenage partner violence is already up and running and getting very good feedback. Also I met with ministers last week and the DCFS have welcomed the recommendations for schools regarding gender equality and media literacy, and many of these are expected to be taken forward as well.’ ‘The report was rigorously researched and is evidence based – conclusions are derived from an in-depth, critical literature review as well as evidence hearing sessions from clinicians and frontline workers in the area,’ Papadopoulos said. ‘The findings are in accord with the APA report on sexualisation as well as the Australian government report in this area. This does not mean that we don’t need more research. For obvious reasons, outlined in the review, longitudinal research in this area is not yet available.’ For other psychologists who are invited to author reports by the government, Dr Papadopoulos had the following advice: ‘Make a lot of space in your diary! This type of work takes a lot of time and commitment – ultimately though it’s extremely rewarding to be involved in a project that has the potential to make a real difference.’ CJ

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Flexible working benefits health A new Cochrane Review has come to the tentative conclusion that flexible working conditions, in the form of employee control over shifts and gradual retirement, are good for our health (http://bit.ly/bPQysB). Kerry Joyce at Durham University and her colleagues trawled the literature for relevant studies that were

randomly controlled and that compared measures before and after interventions. Ten studies involving over 16,000 employees were identified, covering six types of flexible working arrangement. Four studies on self-scheduling of shifts and one study of gradual and partial retirement reported significant health benefits, for example in terms

of blood pressure and sleep quality. The single study on flexitime found no effects whilst the study into fixedterm contracts found equivocal or negative effects. The researchers called for more well-designed intervention studies. ‘We need to know more about how the health effects of flexible working are experienced by

different types of workers, for instance, comparing women to men, old to young and skilled to unskilled,’ said Joyce. ‘This is important as some forms of flexible working might only be available to employees with higher status occupations and this may serve to increase existing differences in health between social groups.’ CJ

US psychologists target homelessness The American Psychological Association (APA) published a Presidential Task Force Report in February on ways that psychology can help bring about an end to homelessness. Commissioned by the 2009 APA President James Bray, the report calls on psychologists to ‘redouble their efforts’ to help the two to three million Americans who experience an episode of homelessness every year. Homelessness occurs as a consequence of a ‘cascade of economic and interpersonal risk factors’ that converge on people ‘marginalized in society’, the report says. The homeless in America tend to have poorer physical health than people with homes, it continues, and are more likely to experience periods of hospitalisation.

DAVID BACON/REPORTDIGITAL.CO.UK

Another assertion, perhaps more surprising, is that the majority of the homeless population do not have a mental illness or substance abuse problem, although prevalence rates for both are higher than in the general population. Other psychosocial factors linked to homelessness, mentioned by the report, include child welfare involvement and institutionalisation. Up to 30 per cent of children in the US foster care system have homeless parents. Moreover, children who leave foster care, either by running away or turning 18, are at increased risk of homelessness. Regarding institutionalisation, the statistics show that homelessness is far higher among jail inmates than the general population and former prisoners are also at increased risk for becoming homeless (former prisoners are also more likely to reoffend if homeless). Veterans are also at increased risk of homelessness, comprising 13 per cent of all adults (unaccompanied by children) who live in sheltered accommodation. At the heart of the report is a call for greater recognition that providing more housing is not enough on its own to eliminate homelessness. Psychological needs must be addressed too. Psychologists can help, the report says, not only through providing clinical services, but also Californian farm workers by their makeshift shelters through training other service

read discuss contribute at www.thepsychologist.org.uk

providers and volunteers; by advocating at state and federal levels for better services and educational opportunities for the homeless; and by conducting research to find out which interventions work and how to encourage greater service take up among the homeless. To improve psychologists’ ability to help the homeless population, the report calls for changes to be made to graduate school curricula and new work placements to be developed. ‘Through research, training, practice and advocacy, the field of psychology can make invaluable contributions toward the remediation of homelessness,’ said James H. Bray. ‘The report of this task force is a call to our profession to work to end homelessness, which is a major public health concern.’ CJ I See http://bit.ly/bcwl2g for the report, p.284 for a feature on homelessness and p.360 for a ‘One on one’ with James Bray.

MEMORY SERVICE A psychologist will be among the specialist staff at a new outreach memory service that was launched in Westminster in February at the Royal Society for Public Health. The ‘Westminster Memory Service’ will provide memory assessment, support, information and counselling to people with memory problems and their carers. The aim is to help detect memory loss in its early stages and to provide support so that people with dementia can stay in their homes for longer.

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Doubt about doubt Can confidence ever be a bad thing? What if it happens to be confidence in your own self-doubt? In a pair of mind-bending experiments Aaron Wichman and colleagues show that doubt layered on doubt doesn’t lead to more doubt but rather to increased confidence, as the initial self-doubt is undermined. The researchers say their findings have clinical implications – for instance, by turning a belief that one is definitely going to fail into a belief that one might fail, a therapist could help inspire a client to overcome the paralysis of hopelessness. First off, Wichman’s team measured the chronic uncertainty of 37 participants (by testing their agreement with statements like ‘When bad things happen I do not know why’). Half these participants also completed a sentence-unscrambling task designed to surreptitiously sow doubt. They had to organise jumbled words into sentences and many of the words, like ‘uncertainty’, pertained to doubt. The other participants performed an almost identical task but without any doubtrelated words. After this, the participants read some imaginary scenarios, such as an employee getting a pay rise, and rated their confidence in the different possible causes of these scenarios. The key finding here was that the doubtinducing sentence task led usually uncertain participants to be far more confident in their judgements about the imaginary scenarios. Participants appeared to be doubting their own doubts, leading to confidence. A second study built on these findings, showing that one doubt-inducing task followed by In the March issue of the another led to more confident Journal of Experimental Social behaviour. Participants first Psychology, Aaron Wichman and wrote about real-life instances colleagues speculate on the of doubt and then completed a clinical significance of doubting coordination task that required self-doubt them to shake their head from side to side, as if saying ‘no’ (past research shows that this instils doubt, whereas nodding increases confidence). These double-doubt participants subsequently rated an imaginary character Donald as more confident and certain – the opposite of what you’d expect if the two doubt-inducing procedures had added together to make more doubt. By contrast, participants who wrote about a reallife instance of doubt and then completed a nodding task, subsequently rated Donald as unconfident and uncertain, consistent with the idea that the secondary nodding task had reinforced the doubt sown in the writing task. ‘One might speculate that the difference between being certain of one’s agonising insecurity and lack of worth and being uncertain of it may mean the difference between suicide and scheduling an appointment for psychological therapy,’ the researchers said. ‘Sometimes, self-doubt reduction might be achieved by instilling doubt in one’s doubt.’

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Trampoline tricks illuminate irony In the March issue of the Journal of Child Language People hold strong feelings about the meanings of irony and sarcasm. Just look at the reaction to Alanis Morissette’s song Ironic – although a hit, her apparent misunderstanding of irony provoked derision (http://bit.ly/10HOCT). So it’s with some courage that Melanie Glenwright and Penny Pexman have chosen to investigate the tricky issue of when exactly children learn the distinction between sarcasm and irony. Their finding is that nine- to tenyear-olds can tell the difference, although they can’t yet explicitly explain it. Four- to five-yearolds, by contrast, understand that sarcasm and irony are nonliteral forms of language, but they can’t tell the difference between the two. So that we’re all on the same page, here’s what Glenwright and Pexman recognise as the distinction between sarcasm and irony. In both cases the speaker says the opposite of what they mean, but whereas an ironic statement is aimed at a situation, a sarcastic remark is aimed at a person and is therefore more cutting. Glenwright and Pexman presented five- to six-year-olds and nine- to ten-year-olds with puppet show scenarios that ended with one of the characters making a critical remark. This remark could be literal, aimed at a person or situation, or it could non-literal, again aimed either at a person (i.e. sarcastic) or situation (i.e. ironic). To illustrate: two puppets are playing on a

trampoline, one falls on his face. ‘Great trampoline tricks,’ the other character says, sarcastically. Contrast this with two puppets playing on a saggy trampoline with little bounce. One of them says ‘great trampoline’, an ironic remark. To gauge the children’s depth of understanding, the researchers asked them to rate how mean the utterances were (using a sliding scale of smiley to miserable faces) and asked them which character they most identified with – the idea being that sarcasm would lead them, out of sympathy, to identify more with the target of that sarcasm. The children’s responses showed that both age groups recognised the non-literal utterances as intending to mean the opposite of what was said. However, only the older age group showed a sensitivity to the difference between irony and sarcasm. They, but not the younger children, rated sarcastic utterances as meaner and were more likely to identify with the target of sarcasm, presumably out of sympathy. The older children’s comprehension was not complete, though. In openended questioning they were unable to explain their differential response to sarcasm and irony. ‘By nine to ten years of age, children’s sensitivity to the distinction between sarcasm and verbal irony highlights their impressive understanding of how people’s feelings are affected by others’ speech...’ the researchers said. ‘We investigated one distinction here, but there are other nonliteral forms that should be examined, such as understatement and hyperbole.’

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Left half of the brain is the real big head

Can therapists tell when their clients have deteriorated?

In the March issue of Cortex

In the January issue of Clinical Psychology and Psychotherapy Psychologists have used an inventive combination of techniques to show that the left half of the brain has more selfesteem than the right half. The finding is consistent with earlier research showing that the left hemisphere is associated more with positive, approach-related emotions, whereas the right hemisphere is associated more with negative emotions. Ryan McKay and colleagues used a version of the selfesteem ‘implicit association test’ (IAT). This compares how readily participants associate themselves or other people with positive words like ‘capable’ and negative words like ‘boring’. Forty-six participants used keyboard keys to categorise words as self-related (e.g. ‘me’, ‘myself’), other-related (‘they’, ‘themselves’), positive or negative. To take one example, people with high self-esteem should be relatively quicker when the same response key is used to categorise self-words and positive words, than when the same key is used to categorise other-related and positive words. A key twist to this study is that McKay’s team used an auditory version of the IAT – the first time this has ever been done. Specifically, they used so-called ‘dichotic presentation’ such that when a word was presented via headphones to one ear, the same word was played backwards to the other ear. This has the effect of ensuring that the word is only processed by the hemisphere opposite the presenting ear, thus allowing the participants to

perform the IAT test with just one hemisphere at a time. As you’d expect, a participant’s self-esteem as measured via one hemisphere tended to correlate with their self-esteem as measured via the other hemisphere. More intriguingly, however, a consistent finding was that participants clocked up higher self-esteem scores when hearing words via their right ear (processed by the left hemisphere) compared with via their left ear (processed by the right hemisphere). Critics may point to the language dominance of the left hemisphere as a major confound, but actually this is not relevant – even if the left hemisphere were faster overall, there’s no reason it should have shown a specific advantage for associating the self with positive words. The researchers said further investigations are needed to build on this initial discovery, including lesion studies and brain imaging techniques.

About 5 to 10 per cent of the time, people in therapy get worse instead of better (see www.bps.org.uk/harm). Now a new study has found, rather alarmingly, that the vast majority of therapists appear blind to such deterioration. Derek Hatfield and colleagues took advantage of symptom feedback provided by clients prior to weekly sessions at a student counselling centre. Although placed on record, this outcome data wasn’t fed back to the therapists in a systematic way, and there was no alert in place to signal symptom deterioration. Hatfield’s team identified 70 clients who at one particular session were in significantly worse shape compared with their state before the very first session. In only 15 of these 70 cases had the therapists made a clinical note after the relevant session suggesting they had noticed a deterioration. The researchers then focused on those cases where a client had shown a huge deterioration

from one session to the next. Unfortunately, it’s still bad news. Of these 41 cases, therapist notes suggested they noticed only 13. When therapists had noted a client deterioration, the most common courses of action were drug referral and continue as usual. When Hatfield then surveyed APA-registered psychological therapists about what they would do, popular answers included ‘discuss the deterioration with the client’ and ‘increase therapy sessions’ – suggestions noticeably absent from the real-life case notes. This research comes with a major caveat – dependence on therapists’ clinical notes is a far from perfect indicator of whether or not they noticed client deterioration. In any case, the researchers said: ‘It is hoped that therapists will be open to the idea that additional information concerning client progress will enhance their clinical judgment, particularly concerning potential client deterioration.’

The material in this section is taken from the Society’s Research Digest blog at www.researchdigest.org.uk/blog, and is written by its editor Dr Christian Jarrett. Visit the blog for full coverage including references and links, additional current reports, an archive, comment and more.

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Subscribe by RSS or e-mail at www.researchdigest.org.uk/blog Become a fan at www.facebook.com/researchdigest Follow the Digest editor at www.twitter.com/researchdigest

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life moving from hostel to street to hostel. This variability is made clear in a 2008 systematic review and meta-analysis of 29 surveys involving over 5500 homeless people across seven Western countries. Seena Fazel at the University of Oxford and his colleagues found huge variability in rates of mental illness and substance abuse from one study to another. Christian Jarrett examines psychology’s response to a disturbing social problem Psychotic illness, for example, was prevalent at 12.7 per cent on average, but ranged from 2.8 per cent to 42.3 per cent (the latter figure derived from a British study of homeless women). Psychosis hen you see a blanket-covered ‘sofa surfers’ – people getting by in the prevalence tends to be reported as higher body shifting uncomfortably in lounges of friends and family? by studies using mental health a doorway, hole-ridden boots According to the latest official UK professionals to do the interviewing, protruding at one end, matted hair at the government figures released in June 2009, whereas the opposite is the case for other, what do you think? That we don’t there are currently over 60,000 depression. have enough houses? That the person in households living in temporary These figures are focused on question should get a job? Do you feel accommodation homelessness in the West and compassion or disgust? of one kind or particularly in the UK, but it’s The reality is that the filthy, dirt-poor another. important to recognise how person you’re looking at may well have Focusing on the picture can vary across been abused or neglected as a child. rough sleeping, cultures. To take just one They’ve no doubt been rejected time and the latest figures example, Yoshihiro Okamoto again. They’re almost certainly in bad for England, compared the demographic health, physical and mental, and could based on counts characteristics of a homeless be addicted to alcohol, drugs or both. If carried out sample in England with a they’re female, it’s likely they’ve suffered between January survey of rough sleepers in domestic violence. 2007 and June Nagoya, Japan – a country Until recently, research on 2008 across 74 that only acquired a word for homelessness was focused on economic local authorities, the homeless after World War issues and social policy. But gradually suggest that 483 II. Compared with the People losing homes to psychology and society are waking up people on English sample, homelessness repossession have a different story among women was virtually to the psychological processes that lead average sleep to those fleeing domestic abuse many people to become homeless in the rough every non-existent in the Japanese first place. Researchers are trying to pin night (87 per sample. Homeless people in down how people end up with nothing cent of whom are Nagoya also tended to be and how to get them back on their feet. male), although this is likely to be an older and to have been homeless for Therapists are listening to homeless underestimate. Over the course of a year, longer. people’s stories, equipping them with London outreach teams see around 3000 the skills to cope and move on. different people sleeping rough at some Identifying the causes of point. People who’ve been in prison or the homelessness care system are at increased risk and Who are they? The question of what causes homelessness there’s a growing trend for rough sleepers It’s easy to slip into the habit of talking in the first place has political undertones – to be from Central or Eastern Europe. about homeless people as if they are does the blame lie with poverty and the The plight of a family forced by a homogeneous group, but it’s more lack of social housing or does it sit with poverty to leave their home is different complicated than that. Do we count just individuals, their histories, the choices from the story of a woman fleeing those sleeping rough on the street or do we domestic abuse, or a man with a they’ve made? It’s also an extremely also include hostel residents and so-called difficult question to research – the itinerant diagnosis of schizophrenia who’s spent his

Helping the homeless

bibliography

W

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American Psychological Association (2009). Helping people without homes. Report of the 2009 Presidential Task Force on Psychology’s Contribution to End Homelessness. Washington, DC: Author. Bonner, A., Luscombe, C., van den Bree, M. & Taylor, P. (2009). The seeds of exclusion. Retrieved 2 March 2010 www2.salvationarmy.org.uk/seeds Christian, J. & Armitage, C.J. (2002).

Attitudes and intentions of homeless people towards service provision in South Wales. British Journal of Social Psychology, 41, 219–231. Cutuli, J.J., Wiik, K.L., Herbers, J.E. et al. (in press). Cortisol function among early school-aged homeless children. Psychoneuroendocrinology. Department for Communities and Local Government (2008). No one left out: Communities ending rough sleeping.

London: Author. Fazel, S., Khosla, V. Doll, H. & Geddes, J. (2008). The prevalence of mental disorders among the homeless in Western countries. PLoS Medicine, 12, e225. Okamoto, Y. (2007). A comparative study of homelessness in the United Kingdom and Japan. Journal of Social Issues, 63, 525–542. Pluck, G. ,Lee, K-H., David, R. et al. (in

press). Neurobehavioural and cognitive function is linked to childhood trauma in homeless adults. British Journal of Clinical Psychology. Maguire, N. (in press). Cognitive behavioural therapy for the homeless population: A pilot study. Behavioural and Cognitive Psychotherapy. Maguire, N. Grellier, B. & Clayton, K. (2009). The impact of CBT training and supervision on burnout, confidence and

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nature of the homeless population makes longitudinal research problematic, and families who would normally provide historical information are often estranged or absent. Marianne van den Bree at the University of Cardiff is one of the psychologists attempting to chart a course through these choppy research waters. Together with colleagues she’s conducted in-depth interviews with 967 homeless people taking refuge in Salvation Army Centres across the UK and Ireland. One of the most striking findings was that just over a quarter reported being homeless before they were eighteen. Thirty per cent also said they’d been emotionally abused in childhood, 25 per cent said they’d been physically abused and 3 per cent sexually abused. Eighty per cent of respondents were found to have one or more substance misuse problems and almost three quarters had mental health issues. Van den Bree also recently conducted an American study with the advantage of a longitudinal design and found similar results. Over ten thousand teenagers were interviewed in 1994 and 1995 and then followed up in 2001 by which time just over 4 per cent had experienced homelessness. The only independent significant risk factors in adolescence were family relationship quality, school adjustment problems and being a victim of violence. ‘I’m realising more and more that a cascade of risk factors may precede homelessness,’ van den Bree says. ‘There are people who almost from birth onwards may be struggling with many adverse factors, and these can accumulate in adolescence and adult life, culminating in something as debilitating as losing your home and having to live on the street or in a shelter.’ Evidence for the pervasive detrimental effect of childhood trauma in the homeless was provided by a study,

negative beliefs in staff group working with homeless people. Manuscript submitted for publication. van den Bree, M.B.M., Shelton, K., Bonner, A. et al. (2009). A longitudinal population-based study of factors in adolescences predicting homelessness in young adulthood. Journal of Adolescent Health, 45, 571–578.

Encouraging service take-up A persistent difficulty for professionals working in this field is that so many homeless people choose not to take up the services that are available to them. Psychologist Julie Christian at the University of Birmingham and colleagues such as Dominic Abrams and Chris Armitage have been investigating this issue for over 16 years and their consistent finding is that psychological factors, such as feeling in control and believing a service will be useful, are far more predictive of service take-up than demographic factors, such as age and gender. A 2002 study involving 104 people in Bridgend and Swansea, for example, found that attitudes to an outreach programme – perceiving it to be of likely benefit – was the most powerful factor predicting intentions to use the programme. Believing that friends would be using the service and perceiving the services to be easily reachable were also significant factors. ‘Our research shows that deep-seated individual differences aren’t based on demographics like age and gender,’ says Christian, ‘but that there’s a lot of experiences that homeless people have that transcend those boundaries – a lot of the same kind of feelings going on for young homeless people are exactly the same as for those who are older.’ Christian says this has implications for the way homeless services are currently funded and marketed to the homeless Dr Suzanne Elliott outside population. Whereas services are currently targeted at a particular a project for homeless demographic, Christian says it’s more important to think about people in Leicester psychological factors. Take the example of feeling in control, Christian says the right approach is ‘finding ways, besides formal committees, so that people can feel as though they have control over their utilisation of a service’. Another practical hindrance to service take-up is excessive paperwork – pen-and-paper assessments, questionnaires and opt-in systems. ‘This can be a barrier to attendance due to literacy problems,’ says Dr Suzanne Elliott, who heads a service in Leicester. ‘Suspicion of authority figures or institutions (with paperwork denoting professional power) also discourages homeless people from engaging with services.’ One way the Leicester service tries to avoid these problems, Elliott says, is to think about power in their approach to work: ‘No suits and ties or heels, no jargon, and being clear about the limits of confidentiality so that people are able to make informed choices about what they disclose.’

currently in press, that measured cognitive performance in 55 homeless adults in Sheffield. Graham Pluck and his colleagues found that the mean IQ for the group as a whole was well below average, at 88. Moreover, those participants who reported having suffered more childhood sexual abuse, emotional neglect and physical neglect tended to have lower IQ scores and exhibit more apathy, disinhibition and executive dysfunction, as indicated by the frontal systems behaviour scale. A potential physiological mechanism for these chronic effects was highlighted by another recent study that involved taking saliva samples from 66 young children at an emergency shelter for families in mid-Western USA. Cutuli and colleagues found that those children who’d experienced more negative lifetime events, including witnessing violence and being separated from their parents, tended to have higher morning levels of the

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stress hormone cortisol. A history of more negative life events also influenced the way the children’s cortisol levels were affected by a series of cognitive tests.

Breaking the cycle For homeless people with a complex, traumatic background, the elusive goal is often not to find hostel places, it’s to keep hold of them. Many are trapped in a cycle in which their aggressive behaviour or substance abuse leads them to be ejected from hostels and back onto the streets. ‘Getting kicked out is another rejection,’ says Dr Nick Maguire at the University of Southampton. ‘It’s another “life’s not fair” experience, which just contributes further to the negative view they have of themselves.’ Maguire tells me about a pilot research project he ran that aimed to break this cycle. At its heart was the provision of cognitive behavioural therapy (CBT) to

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hostel residents. ‘The theory behind this approach,’ Maguire explains, ‘is that most people in the homeless population, but especially repeat homeless – those in hostels or sleeping rough – will have had a difficult childhood experience, which leads them to maladaptive coping, in terms of using drink and drugs and the display of aggressive behaviours.’ Ongoing research suggests this link between childhood neglect and later substance abuse is mediated by emotional dysregulation – that is, having a quick temper, being easily upset, and not having the skills to self-sooth. Most of us who’ve had a safe and loving upbringing acquire the vocabulary to articulate our thoughts and feelings, we develop the skills to regulate our own emotions. By contrast, people with an abusive background turn to external ways of dealing with their emotions, including drink, drugs and self-harm. For the CBT trial, four homeless men who’d experienced repeated tenancy breakdowns took up residence in a hostel where they received individual weekly CBT sessions with Maguire. ‘The aim was to try to enable the men to use more effective strategies to deal with the world and with their emotions,’ Maguire says. The hostel support staff were also given weekly supervision and trained by a psychologist in the basics of the cognitive approach. Early results were promising. Ten weeks into the project, all four of the residents had kept their places at the hostel, and all of them had reduced their thieving, violence and alcohol consumption compared with before the project. Maguire had hoped to pursue the research further but for the moment

funding is lacking. ‘Housing tends to sit in the local authority remit, which is where the funding initially came from’ he says, ‘but they don’t want to be funding what they perceive to be a health intervention. At the same time, the Department of Health don’t want to fund it because they see it as the responsibility of the local authority – so the psychological care of this population often falls between the two.’

People on the Cardiff Night Bus – a mobile outreach service for the homeless

On the ground One of the country’s few dedicated psychological services for the homeless is in Leicester, headed up by Dr Suzanne Elliott. Homeless people in the city can self-refer, bypassing the need for a GP and a fixed address, and are generally offered around 15 sessions of individual or group work, with the option of returning for more after six months. ‘To make the service as accessible as possible I try to meet people wherever it suits them,’ says Elliott. ‘I’ve even worked with clients on a park bench, although not recently. More often it means meeting people in their hostel or at the day centre.’ Much of Elliott’s one-to-one client work is focused on establishing a trusting relationship. ‘We know that a good therapeutic relationship is crucial to successful therapeutic work, but many of the people I work with have never had a reliable, stable, consistent trusting relationship with anyone,’ she says. Many of Elliott’s experiences chime with Maguire’s work in which he helps people learn to control their emotions. ‘People

The APA call to end homelessness In 2009 the American Psychological Association President James Bray commissioned a Presidential Task Force report on ‘Psychology’s Contribution to End Homelessness’, the results of which were published in February this year (see http://bit.ly/bcwl2g). Among the report’s recommendations was a call for homelessness to be incorporated into graduate psychology curricula and for psychologists to educate other service providers and the public at large about the psychosocial factors associated with homelessness – including a history of maltreatment as a child and being a victim of domestic violence. However, the report takes pains to explain that whilst people with mental illness are at increased risk of becoming homeless, the majority of homeless people in America do not have mental health issues. That said, the report also calls on psychologists to advocate at a state and federal level for homeless people to be provided with adequate mental health services, alcohol and drug rehabilitation programmes and educational opportunities. ‘Through research, training, practice and advocacy, the field of psychology can make invaluable contributions toward the remediation of homelessness,’ says Bray. ‘The report of this task force is a call to our profession to work to end homelessness, which is a major public health concern.’

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get referred for anger management a lot, although the anger is often more of a problem for services than for the person themselves,’ Elliott says. ‘Often when I meet the person, I can see that they’ve got every right to be angry – but it’s about using that anger in the right way and trying to find a way so that it doesn’t become an obstacle to being housed.’ Often the sessions involve the homeless client coming to terms with abusive experiences from the past, having them acknowledged and heard. ‘If someone’s been in violent relationships,’ Elliott says, ‘it’s thinking about how this process works and learning how to identify the same situation arising again in future relationships.’ When it comes to group work, Elliott focuses on providing sessions for the 60 per cent of homeless women who have been victims of domestic violence. The groups are led by Elliott and a mental health nurse and they follow the Freedom Programme, which is based on the feminist Duluth model. ‘I’d like to do more group work,’ Elliott says, ‘but for many homeless people it’s very difficult for them to share their experiences with others. For many, their lives are so much about survival and they need to be careful about what they share about themselves. The local homeless population can feel at times like a small community – if, for example, we were running a group on anger and one person related how she was abused in the past, she might worry that someone else in the group knows her abuser.’ Other psychological services provided by Elliott and her colleagues, in a multidisciplinary team including mental health nurses, psychiatrists and support workers, include: cognitive assessments, for example to establish whether a homeless person has memory problems or a learning disability; consultancy to local tenancy support teams, for example providing advice to staff on how to help people who are difficult to work with or who are at risk of losing their tenancy;

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and offering teaching and supervision to trainees from the university. Elliott also provides advice to a residential community for people who have longterm alcohol problems and who are homeless. Recently she’s been working with them to deal with local off licences who sell alcohol on credit to people who they know have alcohol problems. Elliott says there are unique challenges to working with homeless people, particularly in relation to their transience and the frequent crises that tend to occur in their lives. ‘You might start work on goals you’ve set together,’ she says, ‘and then during the six months that you’re working with them, they’ll have three or four crises, which means that the original goals have to be put on hold.’ But despite these challenges, Elliott remains positive about her role. ‘One of the things I love about working in this service’, she tells me, ‘is that I get to meet people from all different walks of life, who’ve got all sorts of histories. I never quite know who I’m going to meet next.’

Supporting the support staff Another city with a dedicated psychological service for the homeless is Brighton. The service was set up and run for several years by psychologist Dr Vicky House before she left last year. The Brighton team provides one-to-one therapy, including CBT and motivational interviewing, for homeless people, but when House arrived there was a particular focus on supporting the staff who work with the city’s homeless population. ‘When I got involved in establishing the service,’ House says, ‘it was clear that we needed to think strategically about how our relatively small psychology resource – at that time me and three assistant psychologists – could maximise its reach and impact on a population of approximately 1500 homeless people living in hostels and other local supported housing provisions. ‘In talking to service users, it became clear that the support provided by hostel staff and other housing workers was often highly valued. However, we were struck by how these workers received very little in the way of training and support to understand the psychological difficulties their clients experienced and how to work effectively with them,’ House says. As one way to promote and strengthen psychological thinking across the existing supported housing system in Brighton, House’s team decided to set up a website especially for housing support workers in the city. The site provides psychologically informed guidance on

to more people,’ Elliott says. ‘It would also how to deliver effective support, be great if we could start up some kind of including advice on goal setting, working psychologists’ network for people working with distress and understanding in this area as a result of this article.’ motivation. ‘The website also hosts a ‘I think building and strengthening discussion forum where people can share existing specialist professional networks good practice tips,’ House says. ‘Aside would be an extremely positive from the website, we also delivered development,’ House agrees. ‘More needs training modules on understanding and to be done to raise awareness around the enhancing motivation using motivational psychological needs of this marginalised interviewing, and working with strengths group; to research how best to meet these and goals using brief solution-focused needs effectively, and how to prevent techniques. And we offered consultations to staff teams around working with clients homelessness in the first place. However, I also think promoting expertise in with specific tenancy-threatening issues.’ working with social adversity, complex Nick Maguire in Southampton has trauma, and marginalisation needs to conducted some research on the effects extend further into mainstream mental of providing support to support staff – health and social care a group that he says practice.’ experiences high rates of Meanwhile, van den burnout but for whom ‘For the people you see Bree and her colleagues are routine supervision is on the streets and in planning a longitudinal usually lacking. ‘Clinical hostels, it’s psychology study involving homeless supervision is the way over social policy’ Welsh teenagers. ‘We that psychologists keep haven’t started yet, but we’re their morale up,’ hoping to follow them over Maguire says. ‘They time. We’re going to be working with the keep sane through good supervision – charity Llamau, which has a very good talking about not only how cases are track record for remaining in contact with going but the impact they’re having on young people and helping them over a you and being able to use the models you long period.’ know from therapy within supervision. Maguire agrees with Elliott that it Without it, you have no opportunity to would be wonderful if this article could check out beliefs like “I’m just not act as a clarion call for psychologists achieving anything here”, “nothing’s working in this field to come together changing”, but the thing is frontline and form a network. ‘The big thing that workers seldom receive supervision.’ I think is missing in this field, that I think With funding from Westminster we can bring as psychologists, is an City Council, Maguire and his colleagues empirical culture,’ Maguire says. ‘Social investigated the benefits of providing a care settings don’t have this. You just four-day CBT training workshop and six don’t see randomly controlled trials. They months of fortnightly supervision to 30 don’t ask that question “What are you frontline staff from 17 homeless trying to change with your organisations in the Westminster region. intervention?”. That’s the kind of culture Immediately after providing frontline that psychology brings.’ workers with this kind of reflective Yes, psychology in the UK has come supervision, and at six-month follow-up, to the homelessness issue late and rather Maguire and his colleagues observed piecemeal, Maguire says, but now it’s reductions in burnout among staff, a arrived it has important things to say and decrease in negative beliefs about the contribute. ‘For the people you see on the homeless population and an increase in streets and in hostels, it’s psychology over perceptions of effective working. ‘So we social policy,’ he says. ‘This argument has think training in supervision is absolutely been helped in recent years by the work key to reducing burnout among staff and on complex trauma, which certainly boosting morale,’ says Maguire. ‘We need influences my thinking. It seems easy to roll this out more widely.’ to me to formulate links between attachment, interpersonal, emotion The future regulation and behavioural impulsivity Apart from the services in Leicester and problems and the behaviours which lead Brighton, Elliott and House aren’t aware people to become homeless. That’s why of any other dedicated psychology services it’s vital that psychologists up their game for homeless people in the country, in this field’. although there are doubtless other clinical and counselling psychologists working I Dr Christian Jarrett is The Psychologist’s with this population. ‘It would be great to staff journalist. christianjarrett@gmail.com see this kind of dedicated service accessible

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INTERVIEW

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Emergency response psychology in Madrid Teresa Pacheco Tabuenca is interviewed by Vaughan Bell*

lthough psychologists work with the A emergency services across the world, Madrid is one of the few cities that have a team of emergency response psychologists that attend incidents alongside police, the fire service and paramedics. Teresa Pacheco Tabuenca has been with the service since its earliest days and worked in the immediate aftermath of the bombings of the Madrid train network and Terminal 4 of Barajas airport. She talked to me about her work as an emergency responder and the development of disaster psychology in Madrid. Could you tell us a little about the psychology emergency response team in Madrid? The SAMUR-Protección Civil emergency services are part of the Madrid municipal government, and at first the service was just focused on physical health. However, in 1999 we saw the need for specialist attention in dealing with complex psychological situations, and so a team of voluntary psychologists was created within SAMUR, principally responsible for passing on bad news to relatives after traffic accidents. Because of the evolution of emergency psychology and the success of the team, in 2003 the psychology emergency response team was formally created. It consists of six people, on call 24 hours a day, for any psychological emergencies that might occur. To ensure an effective and consistent response we have developed procedures for a range of diverse situations for which a psychologist might be required, including extreme anxiety reactions, overdose, communicating bad news, child abuse, sexual violence, multiple victim accidents and large-scale catastrophes. We have three main areas of work: the first is organising psychosocial interventions in emergency or catastrophe situations (designing procedures, crisis interventions, and coordinating the volunteer psychologists); the second is

with other members of the emergency services (training, psychological evaluations and treatment); and the third is research and education (we give presentations on our approach and results of our work in various pre- and postgraduate courses). Within the day-today running of the service, without counting major catastrophes, the service has attended more than 4500 incidents from 2004 to 2008. What is your role in the service? I attend to people who require psychological attention and psychosocial support after living through a critical incident, such as sudden death of a family member, a road traffic accident or sexual assault; I write reports and follow them up. I also work with members of the

emergency services, such as the police or fire service, who may have been affected by an incident. I also coordinate training and monitor the performance of volunteer or trainee psychologists during incidents as well as giving lectures. What do the other emergency services think of the team? I think that in the last few years, their view of us has changed a great deal. Initially we were ‘the unknown’, that is to say, they didn’t know what a psychologist could be useful for in an area where there weren’t any before. However, I think the effectiveness of the service was demonstrated not only into the day-today running of the service, but also after the Madrid train bombings in 2004, the 2006 ETA terrorist attack on Terminal 4 of Barajas airport and in the recent Madrid plane crash. Multidisciplinary work is fundamental in our field, and if we don’t work with other services, the response will remain incomplete. There is a phrase I read once which I think sums this up well: After the police, the paramedics and the fire service, a team of psychologists now promptly arrive at the scene of a disaster ready to collect the broken spirits.

What are the principles that you use in the treatment of trauma in emergency situations? Our principles are drawn from the theories of Lindemann, developed after a fire that caused 492 deaths, where he studied the psychological and grief reactions in survivors. Also we use the work of Caplan on preventative psychiatry, focusing on secondary prevention, immediately after the incident has occurred. We work, in the majority of cases, about seven to ten minutes after the event. Both theories form the basis of our work, where the effectiveness of the care increases directly in relation to the proximity of the treatment in time and place. The general principles are proximity: to act as close as physically possible to the location of the event to avoid stigmatising those affected by transferring them to a mental health clinic or hospital; and Teresa Pacheco Tabuenca – ‘ready to collect the immediacy: to intervene as broken spirits’

* The interview was held in Spanish. This is Vaughan Bell’s own translation.

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soon as possible to avoid the emergence of symptoms, or, in the case of certain reactions, to work with them. An example of this work would be in the case of sudden or unexpected deaths where feelings of guilt or denial often appear, or in cases of sexual violence where feelings of self-blame, feeling ‘dirty’ or fear can emerge. We also work with an expectation of coping, we communicate positive information about the capacity of the person to deal with the situation, activating their personal resources; and our interventions are based on the principle of simplicity so we rely on brief, simple methods adapted to the emotional state of the affected person. Finally, we focus on what we call unity, or the necessity to integrate and accept lived experience.

psychology research group that evaluates our approach and gives rise to different lines of study.

follow-up serves to inform us about the progress of the patient, if there have been changes in various areas of their life (work, social, family, physical and mental health). In cases where it is possible to detect a problem, we can direct them to the most appropriate services.

Which models of trauma have you The treatment of trauma immediately found to be most useful in your work? The models we use are far from the type after the event has been a controversial used in structured consultation or therapy topic in the academic literature. What as we work in the here and now, in the is the evidence base for the approach same place where the event has occurred, of the psychological response team? The team is pioneering in its approach, only a few minutes after. However, we do and we don’t solely respond to large-scale use techniques from brief situations, but to any situation with a psychotherapies. Principally, the high emotional impact. We treat the first orientation is cognitive-behavioural, step of the ‘health assistance pyramid’ in using, for example, relaxation techniques, mental health [a stepped care approach], distraction, cognitive restructuring, based on basic principals of crisis problem solving and so forth. Also, intervention. We intervene with people psychoeducational work is very who have suffered a life event or a sudden important: to communicate and normalise or unexpected loss, by carrying possible reactions out an in situ evaluation of the that could occur in mental state of the person and the short-, “the Madrid train their immediate reactions to the medium- and bombings… there is situation. We work with their long-term; to allow a before and an after form of emotional expression identification of that day” and their own coping skills, risk factors; to be working with the onset of grief, the link between feelings of guilt, denial, and so on. the first response The ultimate objective of our work is team and the family and to pass on prevention – detection of risk factors, information about necessary tasks like intervention and referral to appropriate the identification and collection of bodies, services if necessary. autopsies, and so on. However, we realise the importance With regard to the limitations of our of paying attention to the quality of our interventions, perhaps it is in following service, so we have a system for the longer-term progress of the patients evaluation of our performance in the we attend to. We follow up some patients field, and we have a reporting system by phone, depending on criteria to do for the degree of care we provide and an with the type of incident, age, social annual assessment of user satisfaction. support and their presentation, but not Furthermore, we also have an emergency everyone is contacted. However, the

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What type of research is lacking in emergency psychology at the moment? I think that because the field is quite new, there are many areas that would be extraordinarily interesting to research. The research in this area normally focuses on catastrophes and the reaction of first-response teams, their resilience, and so on. However, much remains to be studied – for example, immediate psychological reactions, coping strategies, the initial stages of shock in survivors of everyday emergency situations. The other area that seems interesting is possibility of applying concepts from positive psychology in our area. What are the most important qualities for a psychologist in the emergency response service? An emergency psychologist has to have specific aptitudes, skills and knowledge – to be especially skilled in non-verbal communication, active listening and empathy, both to give instructions and to work face-to-face; the ability to make decisions under pressure; to be able to lead; to work in a team with professionals from diverse fields; emotional self-control, because we work with people experiencing extreme emotions; to have a high tolerance of frustration as the work is outside the office, in the here and now, where we improve the mental state of the person and help people cope with difficult and unfamiliar situations but without providing the relief of months of therapy; and to know how to formulate constructive self-criticism after each intervention. All of this must be on top of knowledge of protocols, first aid, material used during emergencies and catastrophes and psychological techniques specifically employed in the field (defusing, debriefing, EMDR, etc.). What has been the most challenging situation in your work with SAMUR? Personally, the most difficult situation that I have encountered was the Madrid train bombings. Spain had never experienced an incident of this nature and the communal suffering was immense and difficult to work with. On a personal and professional level, there is a before and an after that day.

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LOOKING BACK

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without striate cortex could respond to light (e.g. Marquis & Hilgard, 1937). Later, Klüver (1942) concluded that they could discriminate only ‘total luminous flux’, but research by the Pasiks and colleagues (1971) showed that the visual capacity could support simple pattern discrimination and detection of gratings. Larry Weiskrantz recalls the conditions surrounding a rare ‘discovery’ Humphrey taught monkeys with V1 in psychology – response to visual stimuli without conscious perception removal to respond impressively to a variety of ‘salient’ visual events, by requiring the animal merely to reach out and touch the source of the visual event (Humphrey & Weiskrantz, 1967). He also t is difficult to pinpoint just when visual sensations become perfect again, studied one monkey, Helen, in the idea of blindsight first emerged, they are able to see minute objects, what considerable detail (Humphrey, 1974), although, as is perhaps usual in such they want is the discernment of things... and showed that she could navigate matters, there are a number of claimants. they are deficient, in a word, of visual herself through an obstacle course. But we can date the year when the word perception’. His conclusion was doubted Despite the animal work, it was ‘blindsight’ was first used – in 1973. Its by William James, without citing his commonly and persistently held that oxymoronic properties were such that it evidence, who referred in 1886 only to humans were rendered completely blind soon found frequent usage, sufficient to Luciani’s work translated from the original following removal or damage of all visual make its entry into the Oxford Concise Italian into German, failing strangely to cortex (although there were some Dictionary – ‘a condition in which the mention an excellent English translation discrepant neurological reports, for sufferer responds to visual stimuli without (by one of the editors of Brain) of the example by Teuber and colleagues (1960), consciously perceiving them’. That original Italian that appeared in that Riddoch (1917), and Bard (1905)). The condition is a lesion or removal of the journal two years earlier. disparity between the human and animal visual cortex (striate cortex, V1) in the That there should be a total loss evidence was puzzling and to many occipital lobes of humans. of visual function after V1 removal has seemed unbridgeable. It led to a history of Historically a more absolute and very become increasingly paradoxical as it speculations by Marquis and others in the persistent conclusion had been held, became clear that 1930s that there was pithily summarised by William James the retina projects ‘encephalisation of (1890, p.47): to several targets in function’ as the “The background to blindsight The literature is tedious ad libitum… the brain other phylogenetic tree was extends over a long period and The occipital lobes are indispensable than the major ascended, although a there is no unique discoverer” for vision in man. Hemiopic input to V1 (via review of the evidence disturbance comes from a lesion of the thalamic dorsal did not lend support either one of them, and total lateral geniculate (Weiskrantz, 1961). blindness, sensorial as well as nucleus). The largest of these non-striate It is rare for patients to have damage psychic, from destruction of both. pathways – the superior colliculus – is to the visual cortex in both hemispheres; larger than the intact auditory nerve in more commonly the damage is to one Indeed, James also held a similar view for hemisphere leading to loss of vision in primates. The output from the superior such a condition in the monkey – that the colliculus can, in turn, reach a large the contralateral half-field of vision, a blindness was absolute and permanent. hemianopia. But within that region, too, number of cortical and other targets. But he did so by ignoring Munk’s the defect was thought to be absolute, in There are also projections from the retina conclusion, that ‘very gradually vision contrast to the residual visual sensitivity to the pulvinar nucleus in the thalamus, slightly improved so that he will not found in the hemianopic field of monkeys and from the lateral geniculate nucleus to bump into things’ (1881, translation by definitively established by Cowey (1967). non-V1 cortical regions. There is no way von Bonin, 1960, p.106). Luciani (1884, One of the first positive clues with of isolating the rest of the brain from a p.153) took this much further from his empirical evidence that the field defect visual input in the absence of V1. own work, concluding that ‘some of a human was not completely inert, Experimental work in the first half of time…after the extirpation, [monkeys’] despite the claims of affected people the 20th century established that monkeys

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retinal ablations. Quarterly Journal of Experimental Psychology, 19, 232–245. Gazzaniga, M.S., Fendrich, R. & Wessinger, C.M. (1994). Blindsight reconsidered. Current Directions in Psychological Science, 3, 93–96. Humphrey, N.K. (1974). Vision in a monkey without striate cortex: A case study. Perception, 3, 241–255. Humphrey, N. & Weiskrantz, L. (1967). Vision in monkeys after removal of the

striate cortex. Nature, 215, 595–597. James, W. (1890). Principles of psychology. London: Macmillan. Klüver, H. (1942). Functional significance of the geniculo-striate system. Biological Symposia, 7, 253–299. Leh, S.E., Mullen, K.T. & Ptito, A. (2006). Absence of S-cone input in human blindsight following hemispherectomy. European Journal of Neuroscience, 24, 2954–2960.

Luciani, L. (1884). On the sensorial localisations in the cortex cerebri. Brain, 7, 145–160. Marquis, D.B. & Hilgard, E.R. (1937). Conditioned responses to light in monkeys after removal of the occipital lobes. Brain, 60, 1–12. Marzi, C.A., Tassinari, & Lutzemberger, L. (1986). Spatial summation across the vertical meridian in hemianopes. Neuropsychologia, 30, 783–785.

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themselves, came from a study by Pöppel forced to use with animals for selective and colleagues (1973), who were discriminations – forced-choice interested in whether visual stimuli responding to alternative visual stimuli – directed to the blind hemifield could we also found evidence for a number of exercise a control over eye movements, other visual capacities (Weiskrantz et al., given the animal evidence that the 1974). superior colliculus played a role in the The rest has become reasonably well control of eye movements. They flashed known to workers in visual neuroscience. a light briefly in different locations in the Elizabeth Warrington (whose major field defects of war veterans and asked contribution has received little publicity) them to look in the direction in which the and I followed D.B. over a 10-year period, flash had occurred. With encouragement, leading up to the Blindsight book in 1986, the subjects played the game, even during which time a variety of visual though they said they could not actually capacities were demonstrated to the see the flash. There surprise not was a weak but only of the positive correlation experimenters between the target but also to D.B. and the eye himself – positions, at least evidence of for eccentricities reaching for out to about 25˚. targets, Alas, these orientation investigators discrimination, stopped with eye visual acuity position as their using gratings, dependent variable. movement, Soon simple shapes, afterwards a etc., in the patient, D.B., came absence of to our attention. acknowledged His right visual awareness by cortex had been him. Since then removed surgically colleagues and I Larry Weiskrantz is Emeritus Professor of to excise a nonI have continued Psychology at the University of Oxford malignant tumour, to follow him over Larry.Weiskrantz@psy.ox.ac.uk causing a left another 25-year hemianopia. There period, recently was evidence in a summarised in clinical setting that he could locate visual a new edition of Blindsight (Weiskrantz, stimuli in his blind field. For example the 2009) spanning the entire 35 years. ophthalmic surgeon at the National A number of other patients have also Hospital, Michael Sanders, noted that been studied by others and us. D.B. could find his outstretched hand The evidence for unconscious visual rather more accurately than one might discrimination was counterintuitive and have expected, and told his colleague challenged directly by critics (e.g. Elizabeth Warrington, who then Campion et al., 1983; Gazzaniga et al., contacted me, knowing of my interest 1994) who suggested various possible in the animal evidence. We repeated the artefacts, such as stray light, or residual study of Pöppel et al., and confirmed islands of cortex. Even more dismissively, their evidence regarding eye positions. because of signal detection theory But with the testing methodology one is considerations, it was claimed (Campion

Mohler, C.W. & Wurtz, R.H. (1977). Role of striate cortex and superior colliculus in visual guidance of saccadic eye movements in monkeys. Journal of Neurophysiology, 40, 70–94. Munk, H. (1881). Über die Funktionen der Großhirnrinde. Berlin: Hirschwald. Pasik, P. & Pasik, T. (1971) The visual world of monkeys deprived of visual cortex. In T. Shipley & J.E. Dowling (Eds.) Visual processes in vertebrates.

Vision Research Supplement no.3 (pp.419–435). Oxford: Pergamon Press. Pöppel, E., Held, R. & Frost, D. (1973). Residual visual function after brain wounds involving the central visual pathways in man. Nature, 243, 295–296. Riddoch, G. (1917). Dissociation of visual perceptions due to occipital injuries, with especial reference to

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et al., 1983, p.427) that ‘from the theoretical point of view the unconscious aspect of blindsight is hence essentially trivial, and from the practical point of view it is impossible to treat scientifically’. There have also been disclosures of even more subtle possible artefacts, and so the guard must remain up. That there should be criticisms is to be expected and even welcomed, although they were sometimes administered with excessive zeal and persistence. On the whole, the early serious criticisms have been addressed and the original position bolstered (reviewed in Weiskrantz, 2009). It is rare for a ‘discovery’ to take place in this area of science, like finding a new continent or a previously unseen butterfly, but it was immediately obvious that the phenomenon of successful performance without awareness in D.B. across a startlingly broad range of visual tasks must have a bearing on the neural and philosophical aspects of consciousness. It is equally obvious that the background to blindsight extends over a long period and there is no unique single discoverer. Indeed, I have always resisted any such label. There have been major contributions from multiple sources: from animal studies and the ever-strengthening evidence for residual function in them; from neuroanatomy; from the acknowledged complexities of neurological clinical examination and purported exceptions to the cortical blindness rule in humans; from behavioural studies of patients like D.B. together with functional MRI imaging; and the prompt given, restricted as it was to eye position, by the evidence from Pöppel et al. (1973). More immediately for me there were richly fruitful discussions with colleagues, especially Elizabeth Warrington and graduate students (subsequently senior colleagues), especially Alan Cowey and Nicholas Humphrey. In fact, it was easier for me personally to accept the evidence about ‘unconscious’ vision given the earlier findings of successful storage without ‘remembering’ in amnesic patients

appreciation of movement. Brain, 40, 15–17. Sahraie, A., Weiskrantz, L., Barbur, J.L. et al. (1997). Pattern of neuronal activity associated with conscious and unconscious processing of visual signals. Proceedings of the National Academy of Sciences USA, 94, 9406–9411. Sahraie, A., Trevethan, C.T., MacLeod, M.J. et al. (2006). Increased sensitivity

after repeated stimulation of residual spatial channels in blindsight. Proceedings of the National Academy of Sciences USA, 103, 14971–14976. Sanders, M.D., Warrington, E.K., Marshall, J. & Weiskrantz, L. (1974). ‘Blindsight’: Vision in a field defect. The Lancet, 1(7860), 707–708. Stoerig, P. (2007). Functional rehabilitation of partial cortical blindness. Restorative Neurology and

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(Warrington & Weiskrantz, 1968), and similar dissociations from awareness in unilateral neglect, aphasia, dyslexia and agnosia (for a review, see Weiskrantz, 1997). Even earlier there was a valuable sabbatical period in the early 1960s with Lucas Teuber in New York, which exposed me to the studies by of him and his colleagues of war veterans with brain damage to visual cortex. If the fixing of a date for blindsight is inherently difficult, at least the invention of the word itself can be dated. In 1973, I was invited to give a talk about our unpublished evidence on D.B. to the Oxford Neurology Department. Shortly before the occasion I was hurriedly asked for a title, and out popped ‘Blindsight and Hindsight’. Soon afterwards ‘blindsight’ appeared in print in a short paper with colleagues (Sanders et al., 1974). (In fact, hindsight in the title of the talk was and is just as important – given the strategic role of the superior colliculus.) So much for ‘Looking back’: what does the future hold for blindsight research? In general, attention is likely to be focused on five main questions, to which I now turn. First, what specific varieties of visual capacity are possible in the field defect, and what bearing might they have on psychological issues? A large variety of visual capacities in the cortically blind field have been revealed recently, among them positive evidence for depth perception, attention enhancement, and luminance contrast (but not colour contrast, thus showing the importance of V1 for colour constancy). One question that has attracted interest is whether emotionally charged visual events might be processed in the cortically blind field (‘affective blindsight’), and if so what anatomical routes might be involved – especially to the amygdala, given its wellestablished role in emotional processing. In one study (Tamietto et al., 2009a) not only were the blindsight subjects able to discriminate between happy and fearful faces in the blind field, but they themselves displayed muscular facial

Neuroscience, 25, 1-14. Tamietto, M., Castelli, L., Vighetti, S. et al. (2009a). Unseen facial and bodily expressions trigger fast emotional reactions. Proceedings of the National Academy of Sciences USA, 106, 17661–17666. Tamietto, M., Cauda, F., Latini Corazzini, L. et al. (2009b). Collicular vision guides non-conscious behavior. Journal of Cognitive Neuroscience.

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patterns appropriate to the two contrasting sets of emotional stimuli. Second, what are the anatomical routes over which such capacities might depend in specific instances? This question is being examined using a variety of methods, and both cortical as well as midbrain routes have been implicated. Future studies of blindsight are likely to try to find out which of these multiple pathways will be involved given the specific processing demands being placed upon them.

Third, what diagnostic tools are available for predicting whether or not blindsight will be found in a region of blindness? Marzi and colleagues (1986) have demonstrated that stimuli in the blind hemifield can influence the behavioural and pupillary responses to consciously perceived stimuli in the intact hemifield: the ‘redundant target effect’. This has been used not only to demonstrate evidence of blindsight, for example in hemispherectomy (Leh et al., 2006), but also to differentiate various possible anatomical routes. For example, when stimuli were of a colour to which the superior colliculus is known to be physiologically insensitive, the redundant target effect in a blindsight subject

doi: 10.1162/jocn.2009.21225 Teuber, H-L, Battersby, W.S. & Bender, M.B. (1960). Visual field defects after penetrating missile wounds of the brain. Cambridge, MA: Harvard University Press. von Bonin, G. (1960). Some papers on the cerebral cortex. Springfield, IL: Charles T. Thomas. Warrington, E.K. & Weiskrantz, L. (1968). New method of testing long-term

diminished, as well as neural activation in the superior colliculus (Tamietto et al., 2009b). Also, pupillary constriction, pioneered in this context by John Barbur at City University, has been found to follow closely the psychophysical profiles for discrimination of stimuli in the blind field (Weiskrantz et al., 1998), and of course also shows a sensitivity to emotional events. Both redundant target effect and pupillometry are likely to be valuable diagnostically in the assessment of various brain lesions in human subjects. Fourth, what are the prospects for rehabilitation, both for increasing sensitivity and also for bringing discriminations into awareness? The evidence from animal research that practice can lead to recovery of visual function following visual cortical lesions (e.g. Cowey, 1967; Mohler & Wurtz, 1977) has spurred similar enterprises with human subjects (e.g. Sahraie et al., 2006). Practical rehabilitation programmes have now been established (see review by Stoerig, 2007). Finally, what differences in brain activity are found between good performance with and without accompanying awareness? In comparing conscious vs. unconscious visual processing, it is essential that the two levels of performance be closely matched. This was satisfied in the first such study for blindsight (Sahraie et al., 1997) implicating frontal lobe foci in fMRI during the conscious accompaniment. Future studies will, no doubt, feed into alternative theoretical and philosophical accounts. Thus, the study of blindsight seems likely to continue to make contributions to psychological phenomena, to anatomy, to rehabilitation, as well as making further inroads into considerations of philosophical and neural underpinnings of consciousness.

retention with special referenced to amnesic patients. Nature, 217, 972–974. Weiskrantz, L. (1961). Encephalisation and the scotoma. In W.H. Thorpe & O.L. Zangwill (Eds.) Current problems in animal behaviour (pp.30–58). Cambridge: Cambridge University Press. Weiskrantz, L. (1997). Consciousness lost and found. Oxford: Oxford University

Press. Weiskrantz, L. (2009). Blindsight. Oxford: Oxford University Press. Weiskrantz, L., Warrington, E.K., Sanders, M.D. & Marshall, J. (1974). Visual capacity in the hemianopic field following a restricted occipital ablation. Brain, 97, 709–728. Weiskrantz, L., Cowey, A. & LeMare, C. (1998). Learning from the pupil. Brain, 121, 1065–1072.

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